Life, Liberty, and the Dementia Patient

Image: Nok Lek/shutterstock.com

Cleaned-up with a nice, strong pin in his hip, Sandy turned out to be one helluva nice guy. Big New York AC member, full of great stories about the plummy old-guard in the great old-days of my rich, old town. Nobody would have guessed; Sandy had been admitted to the medical service five days before I met him, he lay on the floor of his apartment for at least three days before that with the broken hip. Dehydrated, delirious, with pressure sores down to bone all over his back and rear end_—he was saved by his last friend on earth, who hadn’t heard from him in a while, couldn’t raise him on the phone, and so got the landlord to let them in.

The paramedics report said they could barely walk into the apartmenthad to move piles of papers and garbage to get the stretcher in. One half-eaten sandwich, nearly a last meal, sat on the one open space on the kitchen table. Otherwise every surface was covered with stuff and garbage.

Our medical people pulled out all the stops. Cardiology came in because his heart was stuttering. And they got renal because the breakdown products of muscle (ripped around his broken hip and squashed by his body weight on the hard floor) were producing myoglobin, which along with dehydration and low blood pressure was poisoning his kidneys. In the hospitals where I trained, this case would be a “save”a great grand rounds case. But out in the community, especially with no family hovering, the only human audience for all this is the crew taking care of himand sometimes an administrator glad to have opened up an ICU bed. So after a lot of thought, discussion, writing, worry, testing and transfusions, the medical guys told me the story and asked if I would come take care of his hip.

He was still in the ICU. But instead of the shrivelled, unresponsive mess I expected, there was this big smile and huge handshake from an unshaven but definitely handsome seventy-something guy. Sandy was a big man, broad-shouldered and lantern-jawedand as pleasant and clubby as could be. He didn’t remember anything about lying on the floor for three days, he barely complained about the shortened, twisted left leg but he did show the usual, appropriate, queasiness when I dropped the “O” word on him (as in “your hip is broken and needs an Operation”). He seemed familiar and trusted what I told him enough to sign up for the surgery. His penmanship on the consent form was strong, sweeping and evenan airline pilot’s signature. Even though he had arrived in a state alternating between raving and comatose they did let him sign his own consent. (That there was no one else to sign for him made the decision easier.) But Sandy’s mental status was still the pivot around which the rest of his story turned.

As I saw him each morning after surgery there was one consistent thing that Sandy let me know. “I gotta get back home”. This was a motivated patient; he had a goalhome. I had started to tell him about rehab; the great majority of our hip fracture patients go there for a week or so of intensive physical therapy as soon as they are medically stable. Sandy would have nothing to do with this. “Please don’t let them put me in the warehouseI’m fine docjust need to get back to my own bed, feed the cat, catch up on the papers”. I didn’t press the rehab thing, figuring that the case managers whose full-time job is patient-disposition, would deal with it. Maybe it was having a clear goal; he did get better amazingly fastfrom nearly dead to bright and vigorous, walking 150' down the hall, joking with the physical therapists, in less than a week. I was pretty happy with that hip nailing.

“You know you can’t let him go home” was how the case manager broke my bubble. “His apartment was filthy, there’s no one looking in on him and what’s going to happen if he falls again? We’re responsible you know” “There’s an apparatus in place for this kind of caseand we need to get him out of here before it starts costing the hospital. We can’t be stuck with him.”

But anything can happen to anyonethe only thing in the world he wants is to be in his house. He was ok there before and his hip is going to be fine.

“He’s also not too tightly wrapped you knowthe medical people are getting a psychiatrist to have him declared so they can put him into a psych facility.”

I have visited psych facilities and I liked Sandy; I didn’t want him in one. Yes, he didn’t remember being on the floor and he had been foggy on details of timefrom the first day post-op he seemed to regard the hip surgery as something from his distant past. But it’s so easy to lose track of time. He was good on most everything elseor was he? He was a little wacky the way he went off on stories but he really wasn’t any more wacky than so many his age, who were living at home and driving to the supermarket. So I protested. But I did go back to talk to him a little more.

He greeted me with the same big smile and handshake I had gotten twenty minutes earlier. Same concerns about getting home. “Please, can’t you help me Scott?”(Same “we’re working on it” cop-out from me.) Same discussion, different story about the boys at the club, different details. But no reference to my earlier rounds. When I asked, “do you remember what we talked about 20 minutes ago?” he was all smiles and familiar reassurance. But when I asked specifics they were wrong. That was it. He was confabulating. And he had almost no short-term memory. I wouldn’t stand a chance going up against the nursing home proponents. It was a sad realizationin those few words, a little chat about things of no real consequence, this fine American of 75 years had lost his right to self-determination. He was to be consigned, in his own eyes at least, to the rest of his life in prison. For not remembering.

“It’s better for him,” was the standard medical answer. “He’ll be looked after, fed, cleanedoh and there are many activities.”

“And his apartment—_it was so dirty.”

“He could hurt himself.”

“How can he pay his bills?”

Somehow?

I peeked up from the station as the will of the collective was exercised upon my patient. Tightly strapped down, lest he fall and be hurt, they rolled him out of sight.

The care of a loving family could, I guess, save a man from this. Or the firmer embrace of some sweeter danger.

Scott Haig, MD, is an orthopaedic surgeon and a 2018–19 Doximity Author.

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